Happy Titty Tuesday Everyone! This is going to be another “Cost of Breast Cancer” post, because I’m feeling pretty peeved about the letter that I just received from my insurance company in the mail and, 1. I need to blow off some steam about it, and 2. It’s an example of one of the things that women need to deal with during recovery from breast cancer that isn’t talked about enough: insurance.
And finally, this situation is an opportunity for me to be a Fierce Tit in action, so bear with me as I think and write through how I’m going to deal with this situation, and hopefully you’ll benefit from my story so that you don’t make your own $60,000 mistake!
What Happened
Two days ago I picked up my mail from my mailbox and saw a letter from my insurance company. No biggie, I thought. They’ll often send a notice that I’m preapproved for an upcoming mammogram or MRI, and I do have one of those coming up (because I always have one or the other coming up, it seems) so I figured that was what I would see when I opened the letter.
NOT the case. What I saw when I opened the letter was an EOB (Explanation of Benefits) for a shot that I received almost two months ago and have received once since. The EOB explained that this shot was not covered by my insurance, and in the patient responsibility column, the number read just about $6,500. For one shot.
Sidebar: Because my surgeon found a nearly infinitesimal amount of cancer in my lymph nodes in 2018, and because I was 37 when diagnosed, my team recommended the most aggressive chemotherapy and radiation regimen possible. Once I was done with treatment, they proscribed monthly Lupron injections, which stopped my periods and put me into chemically induced menopause. Being in menopause allowed me to take an aromatase inhibitor medication, which my team believed to be the strongest and best chance for me to be completely cancer-free. This medication keeps my body from producing estrogen. And since the type of cancer that I had feeds on estrogen, that’s good, because if there’s no estrogen to feed on, then my body cannot grow more cancer cells.
I have been getting these shots since 2021. I’ve had the same job since then, with the same insurance. I get the shots in the same office where my breast surgeon and oncologist reside. I have always gotten them there, and insurance has always paid up to my deductible and coinsurance.
Until now. And here’s where the plot thickens: Like I mentioned, that was just for January. I still have to get the bill for February. And my March shot is coming up. We’re already at $19,500 for three months.
So this happened because of a small change to my health insurance plan. We were notified of the change last July, and told that it would affect prescription drug coverage. There was a change to the medication tiers in our pharmacy plan. Sure, I thought, and I saw the cost of my aromatase inhibitor pills go up slightly.
But evidently this change affected specialty drugs as well. Like Lupron, which I get every month. In order to be covered by my plan, they need to be dispensed by particular providers in order to be covered.
And this didn’t start in January; it started last July. So that’s 6 more months of payments that I haven’t yet been notified about, because hospital billing takes forever. The total now comes to $58,500. Nearly $60,000.
The out-of-pocket cost of keeping me alive for 9 months: $60,000.
The Strategy
Step One
How I handled it: With a mix of denial and anger. If you’re reading this, you’ve probably gotten these denied claims as well. It’s crazy-making, especially when care that you have been receiving from trusted providers for years is no longer covered. Also, I had difficult flashbacks of the days when I was going through treatment and had to regularly call the hospital and my insurance company to get claims covered that had been rejected. Another post coming soon with the specific letter that I used to get the insurance company to pay for the wig that they at first denied.
I put the letter aside, acknowledged that it didn’t need to be dealt with immediately, and decided to form a game plan.
Step Two
We’re here, writing this post, forming our plan. I’m confused by this one, because there are actually two problems: 1. I need to get the insurance company to pay for the shots I’ve already had, and 2. I need to figure out if I actually have to change where I’m getting my Lupron shots delivered. Taking some time to break down the problem is helpful in forming an approach to the solution.
Step Three
My attempt to solve the problem:
- Call my hospital billing department. In my past experience, they’re less scary and more helpful than the insurance company. Because they put in their own appeals when claims are denied, they’re likely to have the most up-to-date information about these claims. And, in the past they’ve given me helpful suggestions about what to say when I call the insurance company.
- Call the insurance company. Depending on what I hear from the billing department, my next place to call is my insurance company. This may help me figure out what’s happening with my past claims; but they will definitely help me figure out what to do about future claims. They can tell me if I can use the same provider for my Lupron shots, or if I really do need to change providers.
- Call to set up a new appointment for Lupron injections, if necessary.
- Reach out to my oncologist. We’re supposed to have a talk in May about whether I should continue with Lupron anyway. She believes that 5 years on this medication should be enough to protect me from future cancers, and that the benefits I would get from letting my body form estrogen again would be more advantageous than the benefits I would get from staying on the estrogen blockers.
- Not worry. There’s a temptation to absolutely freak out when such a big bill arrives. But I’ve seen enough of them by now to know that sticker shock is a real thing, and also that the sticker price is almost never the actual price. If, after all of my disputes, the insurance company still does not pay the $60,000 worth of claims, I can file for a cost adjustment with the hospital based on my income. The $60,000 number will also get smaller because I will get a discount for not having insurance. (Because even though I had insurance, it did not apply to this situation).
So, I’m going to try and stay calm and remember that I don’t need to freak out at that big number (though it’s so tempting!) I’ll let you know how it goes!